Books

A doctor learns to cope with death

In her new book, a surgeon explores the ways in which physicians respond to dying patients.

Pauline W. Chen, M.D., HS ’98, often recalls the words of the late Yale surgeon C. Elton Cahow, M.D. She once heard him remonstrate with an exhausted resident for thinking he could head home without checking on a certain patient.

“Once you put your hands on a patient,” Cahow said, “they’re yours.”

Chen liked to think she was keeping close watch over all her patients. But something was still wrong: “As early as internship,” she said, “when patients were dying, I found it difficult to go into their rooms, to talk to their families, to discuss their diagnoses and prognoses.” She even shunned a dear friend with terminal cancer.

And her fellow physicians generally shared her anxiety about death. “We’re all susceptible to this,” she said in a recent telephone interview from her home near Boston. “Dying is frightening.”

This fundamental human anxiety, she said, is ratified by medicine’s “hidden curriculum.” When a patient’s death was imminent, Chen often saw attending physicians close the curtain around the patient and the grieving family, and then depart. Chen did the same. “We thought that family members wanted to be alone at the end,” she recalls. “It never occurred to most of us that the actual process might be frightening, and that we could alleviate that fear by being present. And perhaps too, some of us—I include myself here—did not have the insight to realize that we were also leaving them alone because it was easier for us to stay away from the dying altogether.”

“This deeply rooted angst about death,” she later wrote, was being passed on by doctors from one generation to the next “like some tragic hereditary disease.”

Chen said that physicians recognize their limitations. Almost half the oncologists in one study described themselves as only “poor” or “fair” at breaking bad news. Chen herself abandoned a favorite patient to painful and futile end-of-life care because she could not bear to see him diminished by his cancer. In the idiom of her Taiwanese heritage, the young man became a wan ong kuei, a restless soul who haunted her.

Five years ago, pregnant with twins, she took time off from her work as a transplant surgeon at UCLA to care for her daughters and write about the ways in which physicians cope with death. Her book, Final Exam: A Surgeon’s Reflections on Mortality, was published by Alfred E. Knopf in January.

Chen begins Final Exam at the moment when she unveils the cadaver that she will dissect as a medical student. Through anecdotes from medical school at Northwestern and residency at Yale, she traces her growing awareness of the extent to which doctors deny death, and tells of the moment midway through residency when an attending surgeon provided a better model. The surgeon closed the bed curtain around a dying patient but did not leave. He remained inside the curtain, sitting with the patient and family during the final hour of the patient’s life. “It was a major turning point,” Chen recalls. “I realized that I could do more than just cure. I could be there for my patients and their families.” She might offer what the medical anthropologist Arthur Kleinman, M.D., calls “empathic witnessing.”

“My greatest hope for the book,” she said, “is to get people to talk about the issue and to share their anxieties.” Although she recognizes that complex cultural, psychological and institutional forces determine how we cope with death, “the more awareness there is, the greater the chance that we’ll improve end-of-life care for all of us.”

Chen now works full-time as a writer, lecturer and consultant. Her blog carries a link to an excerpt from the book, which was published in The New York Times Magazine last December: www.paulinechen.com.

Bookshelf focuses on books and authors at the School of Medicine. Send suggestions to Cathy Shufro at cathy.shufro@yale.edu.

A digital treasure trove

James D. Jamieson, M.D., Ph.D., professor of cell biology, knew that he had a piece of history in his closet: lantern slides made by the pioneering cell biologist George E. Palade, M.D., and colleagues. Those images of cells seen through the electron microscope had laid the groundwork for Palade’s 1974 Nobel Prize in physiology or medicine. “Palade and his people really formulated, invented and provided the information that started the field of cell biology in the 1940s,” said Jamieson, who did his doctoral work at Rockefeller University with Palade and came with him to Yale.

Jamieson knew that his mentor, who was at Yale from 1973 until 1990, wanted the images to be available to students and scientists around the world. And so Jamieson cleaned the 3.25- by 4-inch glass slides, which Palade left at Yale. Jamieson then digitally scanned 191 slides. Arthur R. Belanger, M.S., project manager of academic media and technology, indexed the slides and placed them on the website of the Cushing/Whitney Medical Library.

The Palade slides are among several digitized collections now available on the website. Other collections include engravings of historic figures and oil portraits of Chinese patients with tumors and other deformities from the mid19th century. The digital collection will expand, said Daniel M. Dollar, M.L.S., associate director of collection development. Palade’s slides helped biologists to relate what they were learning about cell morphology through the electron microscope with what was being discovered about cellular biochemistry through cell fractionation, the process of separating a cell into its distinct parts with a centrifuge.

This holistic understanding of cell function and structure provides the foundation for contemporary understanding of disease processes, because, Jamieson said, “you need to know what’s going on in the normal cell before you begin to figure out what’s going on in the diseased cell.”

Obstetric and Gynecologic Anesthesia: The Requisites

by Ferne R. Braveman, M.D., professor of anesthesiology and of obstetrics, gynecology and reproductive sciences (Mosby) This text discusses anesthesia for female patients during common surgical procedures, including oncologic and nonobstetrical procedures and fetal surgery. Other topics include pain management for high-risk obstetric patients and pharmacology. Each chapter includes case studies.

Management and Treatment of Scars: Procedures in Cosmetic Dermatology Series

by Kenneth A. Arndt, M.D. ’61, HS ’62 (Saunders) This reference presents practical guidance for revising scars using medical treatments, light/laser treatment and surgical and nonsurgical procedures. The book offers step-by-step guidance on proper techniques, pitfalls and “tricks of the trade,” along with photographs and illustrations of cases discussed.

by Glenn E. Good, Ph.D., and Bernard D. Beitman, M.D. ’68 (Norton Professional Books) This textbook aligns students’ classroom experience with the demands of actual clinical practice, in which clinicians do not hew to a single theoretical line but, rather, mix schools and methodologies in order to address their clients’ needs.

Ocular Angiogenesis: Diseases, Mechanisms and Therapeutics

by Colin J. Barnstable, D.Phil., professor of ophthalmology and visual science and of neurobiology, and Joyce Tombran-Tink, Ph.D. (Humana Press) This book surveys current clinical and basic knowledge concerning abnormal growth of blood vessels in the eye. The authors also identify and assess the most promising approaches and discuss the challenges encountered in developing therapeutics for ocular neovascular diseases. This text includes a CD with color versions of figures used in the book.

Visual Development, 2nd ed.

by Nigel W. Daw, Ph.D., professor emeritus of ophthalmology and visual science (Springer) Written for medical students, graduate students and postdocs, this book describes the development of the visual system, the effects of visual deprivation and the mechanisms by which visual deprivation produces its effects.

Menstrual Disorders: A Practical Guide

edited by Deborah B. Ehrenthal, M.D., Matthew K. Hoffman, M.D., and Paula J. Adams Hillard, M.D., with contributions by Henry M. Rinder, M.D., associate professor of laboratory medicine (The American College of Physicians) Designed for the primary care clinician, this book is divided into three sections. The first discusses the adolescent patient, the second covers the range of disorders that patients may experience from adolescence through menopause and the third examines the relationship between menstrual disorders and other medical illnesses.

Extreme Prematurity: Practices, Bioethics and the Law

by Geoffrey Miller, M.D., professor of pediatrics and neurology (Cambridge University Press) This book examines issues surrounding the clinical management of extremely premature neonates in the context of modern neonatal intensive care. The text covers the epidemiology of extreme prematurity and patient care practices in different parts of the world; bioethics considerations, including ethical theories, moral principles and quality-of-life issues; national and international guidelines; and medical law in the United States and elsewhere.

Field Guide to Bedside Diagnosis, 2nd ed.

by David S. Smith, M.D., associate clinical professor of medicine (Lippincott Williams & Wilkins) This book enables students and physicians to navigate the path from collecting information on the patient’s symptoms and presenting signs to reaching a diagnosis. The guide is organized to parallel the diagnostic reasoning process, providing a differential overview of probable causes, a diagnostic approach for each differential diagnosis, and the specific clinical findings that point to diagnosis.

edited by Nathan D. Wong, M.P.H. ’87, and Andrew J. Krentz, M.D. (Informa Healthcare) This text addresses the epidemiology, diagnosis, assessment and management of patients with metabolic syndrome—focusing on implications for cardiovascular disease risk. With tables, flowcharts and practice guidelines, this resource analyzes recent clinical trials, compares and assesses new and emerging therapies and provides recommendations for improving the assessment and treatment of patients.

Principles and Practice of Geriatric Psychiatry

edited by Marc E. Agronin, M.D. ’91, and Gabe J. Maletta, M.D., Ph.D. (Lippincott Williams & Wilkins) This book describes in detail the neurologic and neuropsychiatric patient assessment and the use of all treatment modalities, both psychotherapeutic and pharmacologic, in elderly patients. The contributors discuss the treatment of disorders in all clinical settings: inpatient, outpatient, emergency, primary care, assisted living and long-term care. The book includes case studies and personal accounts by patients and care providers. Appendices provide drug information and list additional resources.

Weight Bias: Nature, Consequences and Remedies

by Kelly D. Brownell, Ph.D., professor of psychology and epidemiology, Rebecca M. Puhl, Ph.D., Marlene B. Schwartz, Ph.D., and Leslie Rudd (The Guilford Press) The authors explore the nature, causes and consequences of weight bias and present a range of approaches to combat it. They discuss topics including the barriers facing obese adults and children in health care, work and school settings; theories on how stigma develops; the impact on self-esteem and health; and strategies for reducing prejudice and bringing about systemic change.